The client will have usual or improved peripheral neurovascular function as evidenced by:

palpable peripheral pulses

capillary refill time less than 3 seconds

extremities warm and usual color

ability to flex and extend feet, toes, hands, and fingers

usual or improved reflexes, muscle tone, and sensation in extremities

no new or increased pain in extremities.

Nursing Actions and Selected Purposes/Rationales

Assess for and report signs and symptoms of peripheral neurovascular dysfunction (check upper extremities after surgery on the cervical area and lower extremities after surgery on the lumbar area):

diminished or absent peripheral pulses

capillary refill time greater than 3 seconds

pallor, cyanosis, or coolness of extremities

inability to flex or extend feet, toes, hands, or fingers

diminished or absent reflexes in extremities

development of or increase in muscle weakness, numbness, or tingling in extremities

development of or increase in pain in extremities.

Implement measures to reduce the risk for peripheral neurovascular dysfunction:

perform actions to reduce strain on the surgical area (see Postoperative Diagnosis 2, action b.1) in order to prevent bleeding and subsequent hematoma formation in the surgical area and to reduce the risk for dislocation of the bone graft and/or internal fixation devices (if fusion was performed)

maintain wound suction and patency of wound drain to reduce the accumulation of blood in the surgical area and subsequently prevent increased pressure on nerves and blood vessels

apply stabilization device properly; notify orthotist if it appears to create excessive pressure on any area

administer corticosteroids (e.g. dexamethasone) if ordered to reduce inflammation in the surgical area.